Stop 'smart pump' medication errors
Stop 'smart pump' medication errors
When used properly, errors 'almost nonexistent'
When a 19-year-old obese woman came to an ED with dyspnea after a recent cesarean delivery of a baby, pulmonary embolism was presumed and an intravenous heparin bolus of 5,000 units was prescribed, followed by a heparin infusion at 1,000 units/hour.
After administering the bolus dose, the ED nurse started the heparin infusion but misprogrammed the pump to run at 1,000 mL/hour, instead of 1,000 units/hour (20 mL/hour). As a result, the woman received more than 17,000 units in less than an hour after her arrival in the ED before the error was discovered.1
This mistake should never have happened, since a "smart pump" with dosing limits for heparin had been used — but the ED nurse bypassed the dose-checking technology and had used the pump in its standard mode. Fortunately, the patient did not experience adverse bleeding, as her aPTT values were as prolonged as 240 seconds when initially measured and 148 seconds two hours later.
'Smart' pumps not foolproof
"Smart" infusion pumps are being increasingly used in EDs to prevent harmful medication errors, but as the above case shows, they are not foolproof.
At Cedars-Sinai Medical Center in Los Angeles, the ED manager and pharmacist conduct random audits to check for override activity of the Alaris smart pumps (Cardinal Health; Dublin, OH), says Flora Haus, MSN, CEN, CNAA, service line manager of the ED. "Proudly, this is not occurring," she says. "Between the pharmacists and myself, whenever we walk around the department we keep our eyes open and scan the pumps. We have not found a work-around in over six months."
That case involved a newer nurse who needed more education on the critical need for the use of guardrails and reminder of the requirement for compliance, and overriding hasn't occurred since, says Haus.
When the smart pumps were first implemented, every ED nurse attended a group inservice and/or one-on-one education, given by the manufacturer's education specialists or one of the ED educators who serve as "super users." "Usually the educators are called upon to refresh someone's memory who may have been off work for while on maternity leave or extended vacation," says Haus.
At University of Chicago's ED, "super users" were sent to inservices provided by Hospira, the Lake Forest, IL-based manufacturer of the smart pumps used in the ED, says Carol Floreza, RN, clinical director of Mitchell Emergency Department at the University of Chicago Medical Center. "We do not run into a large number of problems, except for the more 'seasoned' staff can sometimes be resistant to technology. However, super users are always available in a pinch," says Floreza. "We also consistently do biannual competencies on all of our equipment and target those that we think need additional help."
There is a potential for errors with medications not yet in the smart pump's "library" of preprogrammed dosages, such as some of the newer antibiotics for the treatment of septic shock, but this occurs infrequently, says Haus.
In those instances, the calculations are done by the nurse and double-checked by another nurse, an ED physician, or pharmacist, says Haus. "Those medications being administered in the emergency setting which are outside the recommended range of the pump likewise need to be calculated by the staff and the pump guardrails overridden," she says. "Avoiding errors that result from this rests with the diligence to obtain a second brain and set of eyes."
When used properly, the pumps prevent errors by confirming the rate and dosage for the medication to be infused, says Haus. "It eliminates the human error potential in doing drug calculation," she says. "By standardizing the drip/dose calculations which require weight dosing, errors related to dosing and flow are almost nonexistent."
Reference
- Institute for Safe Medication Practices. Smart pumps are not smart on their own.ISMP Medication Safety Alert! Acute Care2007; April 19, 2007. Accessed at www.ismp.org.
Sources/Resource
For more information about use of smart pumps in the ED, contact:
- Carol Floreza, RN, Clinical Director, Mitchell Emergency Department, University of Chicago Medical Center. Phone: (773) 702-1014. E-mail: [email protected].
- Flora Haus, MSN, CEN, CNAA, Service Line Manager, Emergency Department, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA 90048. Phone: (310) 423-8754. E-mail: [email protected].
Educational tools on effective approaches to implementation of smart pump technology are available from the Institute for Safe Medication Practices (ISMP). To access the tools, go to ISMP's web site (www.ismp.org). Click on "Professional Development," "Continuing Education," and "Effective Approaches to Standardization and Implementation of Smart Pump Technology."
When a 19-year-old obese woman came to an ED with dyspnea after a recent cesarean delivery of a baby, pulmonary embolism was presumed and an intravenous heparin bolus of 5,000 units was prescribed, followed by a heparin infusion at 1,000 units/hour.Subscribe Now for Access
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